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2015; 10(3): 205–208
ISSN-1452-662X
ORAL MANIFESTATIONS OF CROHN´S DISEASE: A CASE REPORT
1 2
Muhvic Urek Miranda, Mijandrusic Sincic Brankica, Braut Alen
1
Department of Oral Medicine, Dental Clinic, University Hospital Rijeka, Croatia
2
Division of Gastroenterology, Department of Internal Medicine, University Hospital Rijeka, Croatia
3
Department of Restorative Dentistry and Endodontics, Dental Clinic, University Hospital Rijeka, Croatia
Primljen/Received 28. 08. 2015. god.
Abstract: Crohn’s disease is a chronic inflamma-
tory bowel disease still with unknown etiology. In
0.5–20% of patients, extra intestinal lesions in the oral
cavity can be presented in forms of orofacial granulo-
matosis, cobblestone and corrugated oral mucosa, mu-
cosal tags, deep linear ulcerations with hyperplastic
folds, pyostomatits vegetans, aphthous ulcers, angular
cheilitis, labial/facial edema and gingival erythema/ede-
ma. We describe a case of a 28-year-old male who was
presented with oral lesions of Crohn’s disease and treat-
ment procedure. The patient was candidate for biologic
treatment so dental procedures and preparation of the
patient for treatment are described. Good communica-
tion and cooperation between the patient’s doctor and
dentist are important for successful treatment.
Key words: Crohn´s disease; inflammatory bowel
disease; oral manifestation.
INTRODUCTION
Crohn’s disease (CD) is a chronic inflammatory
granulomatous disease with primary intestinal invol-
vement but it may involve any part of bowel system
from mouth to anus (1, 2).
The etiology of disease is still unknown but gene-
tic factor, environmental factors and immune response
in the bowel wall seems to be main causes of CD (3, 4).
The disease is characterized by phases of exacer-
bation and remission, with the symptoms of diarrhea,
stomach pain, weight loss and elevated body tempera-
ture (1, 5). One third of patients can exhibit extra intes-
tinal manifestations of the disease (6). The most frequ-
ent manifestations affect the joints, skin, eyes and he-
patobiliary system. Changes in the oral cavity, blood
vessels, heart, lungs and genitourinary and endocrine
system have been also described (6, 7).
Oral lesions of CD were first described in 1969 by
Dyer at al (8). In the same year Dudeney (9) reported
DOI: 10.5937/sanamed1503205M
UDK: 616.34-002-06; 616.31
ID: 219463948
Case report
3
Prihva}en/Accepted 09. 10. 2015. god.
another case of patient suffering from CD who had oral
manifestations. The prevalence rate of oral manifesta-
tions is estimated to be between 0.5 to 20% (5, 10, 11),
although some studies mention up to 80% (12, 13).
They include orofacial granulomatosis, cobblestone
and corrugated oral mucosa, mucosal tags, deep linear
ulcerations with hyperplastic folds, pyostomatitis ve-
getans, aphthous ulcers, angular cheilitis, labial/facial
edema and gingival erythema/edema (10, 14, 15). Pre-
sence of cobblestone mucosa and mucosal tags are
highly suggestive to CD (16).
There is a male predilection and the oral outbreaks
often start in young ages (17). Up to 60% of patients
with CD may present oral manifestations years before
the appearance of intestinal disease (5, 17). Oral mani-
festations are unpleasant bitter, disagreeable, displeas-
ing, and distasteful for the patients; restrict their nutri-
tion and oral hygiene.
The aim of this paper is to present a case of patient
with oral manifestation of CD and treatment procedure.
CASE REPORT
A 28-years-old male patient was referred to the
Department of Oral medicine at the Dental clinic Rije-
ka due to pain in the mouth. Oral complains and lesions
have been presented for 10 days.
The patient medical history revealed that he has
been suffering from CD for five years. He has been su-
bjected to resection of terminal ileum and sigmoid co-
lon in 2010. Post-surgical remission was maintained
with azathioprine therapy for four years. Two months
after stopping the azathioprine therapy, (four months
prior of arrival in our clinic) the disease became active
and the infliximab was recommended. During the pe-
riod of patient’s preparation for infliximab therapy the
patient was referred to the Oral medicine Dental Office
for treating lesions in the oral cavity and excluding oral
206 Muhvic Urek Miranda, Mijandrusic Sincic Brankica, Braut Alen
foci of infection. He has never before experienced oral
lesions since he was diagnosed with CD.
Clinical exam revealed erythema and inflamma-
tion with white to yellow small pustules on the right
buccal mucosa, what was recognized as pyostomatitis
vegetans. Furthermore, in the lower right quadrant on
the vestibular gingiva and in the fornix a thickened, in-
flamed and cobblestone oral mucosa with ulcerations
was presented (Figure 1). Under local anesthesia (2%
lidocaine) an incision biopsy of the altered mucosa and
gingiva was performed. Swabs were taken from the
oral mucosa for the microbiological analysis.
Patient was prescribed a topical antiseptic therapy
(0.2% chlorhexidine gluconate solution three times per
day), corticosteroid (0.05% betamethasone ointment
three times per day), and systemic corticosteroid (pred-
nisolone 30 mg) with proton pump inhibitor.
On recall visit after seven days the sutures were
removed. Clinically the erosions were epithelized and
the inflammation diminished. The patient continued
the prescribed therapy for additional 7 days. The bi-
opsy of the buccal lesion revealed: dense lymphoma
histiocytic inflammatory cell infiltration in the vicinity
of the basal membrane. In the gingiva sample histi-
ocytic granulomas were presented, that all together in-
dicated the presence of Crohn’s disease.
Patient’s dental status was taken, vitality tests we-
re performed, and the panoramic radiogram was ana-
lyzed. No pathological changes were found on the te-
eth or on the surrounding bone. Microbiological results
were negative and from the dental point of view the pa-
tient was eligible to start the biologic therapy.
On the second recall after 14 days the oral mucosa
was normal without pathological changes (Figure 2).
Figure 1. Clinical appearance at time of first
presentation. White to yellow small pustules
on the inflamed buccal mucosa and cobblestone
lesions with ulcerations on the vestibular gingiva
and in the fornix
Figure 2. Clinical appearance at second recall.
There was no oral lesions. The site of gingival
biopsy is visible
Topical therapy was stopped while the systemic pred-
nisolone therapy remained and it was gradually tapered
down under gastroenterology specialist supervision.
Patient was instructed to come for consult after one
month, when there was no oral lesions presented.
After routine preparation for biologic (anti-TNF)
therapy (screening for tuberculosis and viruses), inflixi-
mab induction therapy was administered by which the
remission of Cohn’s diseases was achieved. Infliximab
maintenance therapy was continued by re-administra-
tion every eight weeks. Now, he is in stable remission.
DISCUSSION
We presented the case of a patient who developed
oral manifestations of CD in the phase of reactivation
of the disease, after interrupting of maintenance azathi-
oprine therapy during four years.
Although, in the mouth of patients with CD a vast
variety of specific and nonspecific lesions can be pre-
sented, in our case the pyostomatitis vegetans, cobble-
stone mucosa and ulcerations were observed. In the lit-
erature it is reported that the oral lesions can appear eit-
her before, coincide, or after the onset of symptoms
and lesions in the gastrointestinal system (17–21). The
severity of oral lesions can indicate the activity level of
chronic inflammatory processes in the intestine (22).
Oral lesion can be managed by topical corticoste-
roids such as triamcinolone acetonide and betametha-
sone (23). The topical application of corticosteroids
sometimes is not sufficient and a systematic adminis-
tration of corticosteroids is needed (e.g. prednisolone)
(23, 24). Some authors state that the topical application
of corticosteroids is not sufficient, and treatment must
start from the beginning with systemic corticosteroid
therapy (25). In the presented case, it was decided to
start simultaneously with topical and systemic cortico-
 ORAL MANIFESTATIONS OF CROHN´S DISEASE: A CASE REPORT 207

steroid therapy what resulted in healing of oral lesions.
After 14 days the topical therapy was halted, while the
systemic corticosteroid was gradually tapered down.
Administration of medium high and high doses of
systematic corticosteroids results on disappearance of
lesions, however the lowering of dosage or stopping the
treatment can result in exacerbation of the lesions (26).
For the modern therapy it is unacceptable to keep the pa-
tient in remission with corticosteroids due to numerous
side effects. The azathioprine therapy that was adminis-
tered for 4 years after withdrawal brought the patient to
acute disease exacerbation including oral lesions. The
anti-TNF therapy was the choice for our patient.
However, the initiation of biologic therapy requi-
res strict preparation procedures including detection of
manifest and hidden potential focal infections (27).
The preparation includes exam of oral cavity and teeth
(27). Patient have to present restored teeth, healthy pe-
riodontal tissue and oral mucosa, and the possible oral
foci have to be eliminated. The presence of oral foci
due to immunosuppressive action of the biologic ther-
apy can lead to distant focal infections that can jeopar-
dize the patient’s health and life. Therefore, the dental
exam was performed and the foci of oral origin were
excluded in our patient.
CONCLUSION
In the presented case the findings in the oral cavity
were manifestations of the primary disease and the pa-
tient was treated for the primary disease (with cortico-
steroids, and subsequently anti-TNF biologic medica-
tion). Since the patient was candidate for biologic ther-
apy the foci of oral origin were excluded. For the suc-
cessful treatment of extra intestinal/oral lesions of
Cohn’s disease good communication between gastro-
enterology specialist and the dentist/oral medicine spe-
cialist is essential.

Sa`etak

ORALNA MANIFESTACIJA KRONOVE BOLESTI — PRIKAZ SLU^AJA

1 2 3
Muhvic Urek Miranda, Mijandrusic Sincic Brankica, Braut Alen
1
Department of Oral Medicine, Dental Clinic, University Hospital Rijeka, Croatia
2
Division of Gastroenterology, Department of Internal Medicine, University Hospital Rijeka, Croatia
3
Department of Restorative Dentistry and Endodontics, Dental Clinic, University Hospital Rijeka, Croatia

Kronova bolest je hroni~na zapaljenska bolest cre-
va jo{ uvek nepoznate etiologije. U 0,5–20% pacijenata
mogu se javiti ekstraintestinalne lezije u usnoj duplji u
obliku orofacijalne granulomatoze, kaldrmaste i talasa-
ste oralne sluznice, sluzni~kih nabora, dubokih linearnih
ulceracija s hiperplasti~nim naborima, piostomatitis ve-
getansa, aftoznih ulceracija, angularnog heilitisa, otoka
usana i lica te crvenila i otoka gingive. U ovom radu opi-
san je slu~aj 28-godi{njeg pacijenta koji je razvio oralne
lezije u sklopu Kronove bolesti i postupak le~enja. Paci-
jent je bio kandidat za biolo{ko le~enje te je u radu opi-
san stomatolo{ki postupak pripreme pacijenta za le~e-
nje. Za uspe{no le~enje bitna je dobra komunikacija i sa-
radnja izme|u pacijentovog doktora i stomatologa.
Klju~ne re~i: Kronova bolest; Oralne manifesta-
cije; zapaljenska bolest creva.

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Correspondence to /Autor za korespondenciju
Miranda Muhvi}-Urek, PhD, DMD
Department of Oral Medicine
Dental Clinic, University Hospital Rijeka, Croatia
Kre{imirova 40,
Rijeka HR-51000, Croatia,
Tel: ++38551345634;
Fax: ++38551345630;
Emal: miranda_umªhotmail.com
miranda.muhvic.urekªmedri.uniri.hr
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